Provider Demographics
NPI:1851394423
Name:FREDERICK, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BRADFORD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-6910
Mailing Address - Country:US
Mailing Address - Phone:724-933-1100
Mailing Address - Fax:724-933-1160
Practice Address - Street 1:1600 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:NATRONA HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:15065-2138
Practice Address - Country:US
Practice Address - Phone:724-224-3900
Practice Address - Fax:724-224-9010
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051557L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF75396Medicare UPIN